navigating new york state’s transition to managed carenavigating new york state’s transition to...
TRANSCRIPT
Navigating New York State’s
Transition to Managed Care
December 3, 2014
Mary McKernan McKay, Ph.D
Andrew F. Cleek, Psy.D.
Meaghan E. Baier, LMSW
Agenda
•Introduction of the Managed Care Technical Assistance
Center (MCTAC) and its resources
•Review key areas of readiness that all providers need to
consider ahead of the transition to Managed Care
•Discussion of what changes front line providers can expect
and how they can prepare
•How the transition to managed care fits in with other
initiatives and the broader changing health care landscape2
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� The goal of MCTAC is to provide training and intensive support on quality improvement strategies, including business, organizational and clinical practices to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care
� NYS has partnered with MCTAC as a training, consultation, and educational resource center that offers resources to ALL mental health and substance use disorder providers in New York State
Licensing Office Number of Agencies
OASAS 444
OMH 545
OASAS and OMH 107
UNIQUE ORGANIZATIONS 887
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MCTAC SCOPE
MCTAC is partnering with OASAS and OMH to provide:
• Foundational information to prepare providers for Managed Care
• Support and capacity building for providers
• tools
• group consultation
• informational training
• assessment measures
• Information on the critical domain areas necessary for Managed Care
readiness
• Aggregate feedback to providers and state authorities
• MCTAC will serve as a clearing house for other Managed Care
technical assistance efforts6
Setting the Stage for Managed
Care
Setting the Stage for Managed
Care
GOVERNOR’S VISION FOR MEDICAID REFORM
It is of compelling public importance that the State conduct a fundamental restructuring of its
Medicaid program to achieve measurable improvement in health outcomes, sustainable
cost control and a more efficient administrative structure.”
Governor Andrew Cuomo, January 5, 2011
EXPECTED OUTCOMES:
Improved health status
Improved quality of care
Reduced costs
Care Management for All…..
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Medicaid Expenditures: 2013
$49.1 billion
Managed Care 101…Managed Care 101…
Managed Care: DefinitionManaged Care: Definition
• An integrated system that manages
health services for an enrolled
population rather than simply
providing or paying for the services
• Services are usually delivered by
providers who are under contract to
or employed by the plan
Managed Care: Key IngredientsManaged Care: Key Ingredients
• Care “management”
– Utilization management
– Disease management
• Vertical service integration and coordination
• Financial risk sharing with providers
Managed Care: GoalsManaged Care: Goals
• Control costs
– Health care costs growing faster than GDP
– Reduce inappropriate use of services
– Increase completion: focus on value
• Improve service quality
• Improve population health
• Increase preventive services: promote health
(not just treat illness)
• Network of providers created via contracting
• Medical home created w/primary care provider
functioning as a gatekeeper
• Prior approval required for inpatient admissions,
specialty visits, elective procedures, etc.
• Benefits package defined set of covered services
• Contained list of covered pharmaceuticals
(Formulary)
• Utilization review practices to manage inpatient
admissions and length of stay
Managed Care: Key ComponentsManaged Care: Key Components
• Managed Care Organization receives a fixed payment each
month for each member: Per Member Per Month (PMPM)
• Fixed fee is for a specific time period (typically a month)
– Covers defined set of services (these are the benefits)
• Provider accepts risk for delivering services:
– Agrees to comply with prior authorization and utilization
management practices
– May enter into pay for performance arrangement
How Capitation WorksHow Capitation Works
How Providers May Be Paid How Providers May Be Paid
• Capitation Rate: MD groups, hospitals or
Accountable Care Organizations (ACOs) may
enter into such agreements.
– May include shared risk/savings arrangement
• Negotiated fee for service: some MDs, ancillary
services, labs, etc..
• Per diem/ fixed daily payment: hospitals, SNF
• Payment based upon the episode of care:
– Diagnostically Related Groups (DRGs)- Today
– Acute /post acute bundled payments- Future
Determining Service Provision and PaymentDetermining Service Provision and Payment
�Is the person a member?
�Is the service included in the member’s benefit
plan?
�Is the service medically necessary?
�If authorization is required, has the service been
authorized?
�Is the provider that will deliver the service a part of
the MCO network?
The answers to all of the above questions must be
“YES” if the service is to be paid for by the MCO.
How Might Physicians Be Organized?How Might Physicians Be Organized?
• Medical Group: MDs are employees of the group
• Independent Practice Association (IPA)
– MDs own and operate private practices
– MDs and other service providers may also choose to
become a part of an IPA. Why?
• Functions as a contracting vehicle with the MCOs: Provides
critical mass of providers and covers a broad enough
geography to be interest.
• Functions as a management vehicle: offers business processes
(such as capitation reconciliation) as well as clinical functions (
UM and prior-authorization, etc.)
What Does the NYS Medicaid
Managed Care Program Look
Like Today?
What Does the NYS Medicaid
Managed Care Program Look
Like Today?
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The Publicly Funded Behavioral Health System Today….. The Publicly Funded Behavioral Health System Today…..
Medicaid
Recipient
Medicaid
Managed Care
Organization
Medicaid
Managed Care
Services
Non-Medicaid
Funded Services
Medicaid Carve
Out Services –
Fee For ServiceHigh Risk/High
Need Medicaid
Recipients
Services Not Covered by
Medicaid Managed Care
Recipients Not Covered by
Medicaid Managed Care
Who is accountable for the whole person?
Remaining System ChallengesRemaining System Challenges
• 20% of people discharged from general hospital psychiatric units are readmitted within 30 days.
– A majority of these admissions are to a different hospital.
• Discharge planning often lacks strong connectivity to outpatientaftercare.
– Lack of assertive engagement and accountability in ambulatory care.
– Contributes to: readmissions, overuse of ER, poor outcomes and public safety concerns.
• Lack of care coordination for people with serious SUD problems leading to poor linkage to care following a crisis or inpatient treatment.
• A significant percentage of homeless singles populations has serious mental illness and/or substance use disorder.
Remaining System ChallengesRemaining System Challenges
• People with mental illness and/or substance use disorders are over represented in jails.
• Unemployment rate for people with serious mental illness is 85%.
• 33% of people entering detox were homeless and 66% were unemployed in 2011.
• People with serious mental illness die about 25 years sooner than the general population, mainly from preventable chronic health conditions.
• Poor management of medication and pharmacy contributes to inappropriate poly-pharmacy, inadequate medication trials, inappropriate formulary rules, poor monitoring of metabolic and other side effects and lack of person centered approach to medication choices.
What We Know about the Changes Anticipated…. What We Know about the Changes Anticipated….
RFQ BH Benefit Administration: MCO & HARPRFQ BH Benefit Administration: MCO & HARP
• What will Change?
– All Medicaid recipients will be members of a Managed Care Plan
– More services (including recovery services) covered by Managed Care Plans
– Individuals w/significant needs can become a part of a Health and Recovery Plan (HARP) - receive services not available through the standard BH plan
– Imbeds process / resource changes within a specific philosophical model:
• Person centered, recovery focused practices
• Reliance on care management for high need individuals
• Greater reliance on community services rather than inpatient services
• Service integration
• Greater accountability for achieving outcomes
Services To Be Covered by MCO as of July 1,
2015 (Not paid for by MCOs today)
Services To Be Covered by MCO as of July 1,
2015 (Not paid for by MCOs today)
• Continuing Day Treatment
• Partial hospitalization
• PROS
• ACT
• Rehabilitation services for residential SUD treatment
supports
• Inpatient Psychiatric services (currently FFS for all SSI
Medicaid recipients)
• Rehabilitation services for residents of community
residences (beginning in year 2)
Health and Recovery Plans (HARPs)Health and Recovery Plans (HARPs)
Who is eligible?
•Must either meet the target risk criteria and risk factors or be
identified by service system or service provider identification
Target Criteria:
•Medicaid enrolled 21 and older
•SMI/SUD diagnoses
•Eligible for Mainstream enrollment
•Not dually eligible
•Not participating in OPWDD program
140,000 individuals are estimated to be eligible (60,000 in Upstate
NY)
All will be expected to have a Health Home Care Manager
Let’s not forget:
Other initiatives underway…..
Let’s not forget:
Other initiatives underway…..
• Health Home Care Management
• Delivery System Reform Incentive
Payment (DSRIP) Plan
Health Home Care ManagementHealth Home Care Management
What is a Health Home?What is a Health Home?
• Outgrowth of the Affordable Care Act
• Designed to expand on the traditional medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care for individuals with multiple chronic illnesses
What is a Health Home?What is a Health Home?
• A program that provides Care Management to High Need Medicaid Recipients
• All of the professionals involved in a member’s care communicate with one another so that all needs are addressed in a comprehensive manner.
• Medical, behavioral health and social service needs are to be addressed
Health Home SystemHealth Home System
Community Resources
Individual
& Care
Manager
Health Care Providers
Services Agencies
Education
Vocational Services
Housing
What are the Desired Health Home
Outcomes?
What are the Desired Health Home
Outcomes?
•Improve health care and health outcomes
•Lower Medicaid costs
•Reduce preventable hospitalizations and ER visits
•Avoid unnecessary care for Medicaid members
Delivery System Reform
Incentive (DSRIP) Plan….
Delivery System Reform
Incentive (DSRIP) Plan….
Delivery System Reform Incentive Payment
(DSRIP) Plan
Delivery System Reform Incentive Payment
(DSRIP) Plan
$7.567 Billion over 5 years
Goal: Reduce avoidable hospitalizations by 25% over five years.
Theme: Communities of providers encouraged to work together to develop DSRIP project proposals
•Focus on reducing inappropriate hospitalizations
•Open to a wide array of safety net providers
•Payments are performance based
•Must choose from a menu of 25 CMS-approved programs
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NYS DSRIP: Key ComponentsNYS DSRIP: Key Components
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Rather than think about these
transformational initiatives (BH
Carve In, Health Homes and
DSRIP)as disparate initiatives, lets
consider the alignment that exists….
Transforming the Children’s
System
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– Intervening early in the progression of behavioral health disorders is effective and reduces cost.
– Accountability for outcomes across all payers is needed for children’s behavioral health.
– Solutions should address unique needs of children in a unified, integrated approach.
– The current behavioral healthcare system for children and their families is underfunded.
– Children in other public or private health plans should have access to a reasonable range of behavioral health benefits.
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Children’s BH Team ThemesChildren’s BH Team Themes
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• HCBS
• Clinic
• Day Treatment
• Community Residence
• Residential Treatment Facility
• Inpatient
Existing Medicaid Services will Transition
into Managed Care
Existing Medicaid Services will Transition
into Managed Care
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Proposed New State Plan ServicesProposed New State Plan Services
• Mobile Crisis Intervention
• Community Psychiatric Supports and Treatment
(CPST)
• Other Licensed Practitioner
• Psychosocial Rehabilitation Services
• Family Peer Support Services
• Youth Peer Advocacy and Training
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Proposed HCBS ArrayProposed HCBS Array
• Care Coordination (only for
those ineligible for, or opt out
of, Health Home)
• Skill Building
• Family/Caregiver Support
Services
• Crisis & Planned Respite
• Prevocational Services
• Supported Employment
Services
•Community Advocacy and Support
•Non-Medical Transportation
•Day Habilitation
•Adaptive and Assistive Equipment
•Accessibility Modifications
•Palliative Care
• CANS-NY (Child and Adolescent Needs and
Strengths) undergoing revision to increase
sensitivity in appropriate assessing all
populations under the 1115
• CANS-NY Algorithm under revision to account
for differentiation between LON and LOC, in
addition to use in assigning Health Home
acuity levels and subsequent rate payments
Functional AssessmentFunctional Assessment
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Current Continuum of Care
Intensity of Need
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Understanding your population:
•Develop an agency-wide profile of the client population served and their needs
•Determine which insurance plans your clients are currently enrolled in for physical health, or behavioral health as applicable
•Map out the services you provide now and who provides them (e.g., which types of services and for whom)
•Identify any Home and Community Based Services you provide or that are available in your community
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Some Things to Consider NowSome Things to Consider Now
Mental Health
Child Welfare
Probation
Community Supports
School
Kids & Families Developmental
Disabilities
Juvenile Justice
Pre-K or After-School
Pediatricians
Importance of Cross-System
Collaboration
Importance of Cross-System
Collaboration
Transformational AlignmentCommon Themes Behavioral
Health Carve-In
Health Homes DSRIP
SHARED GOAL: Reduce avoidable ED
and Inpatient
admissions
Reduce avoidable ED
and Inpatient
admissions
Reduce avoidable ED and
Inpatient admissions
SHARED THEMES:
Collaboration New relationship
expectation for MCOs
and Providers
Cross-systems Care
Team required
Essence of Performing
Provider Systems;
mutual accountability
across NYS
Integration Goal for QHP’s
Required for HARPS
Required for Health
Homes (Unfunded)
Required and potential
dollars
Care Management Available through QHP
Required for HARP
New dollars to expand
care management
availability
Tool for achieving DSRIP
goals
New Solutions Flexible supply of
Medicaid payable
1915i Services
Required focus on social
determinants of health
Key to success
Focus on Outcomes Core MCO value Core Health Home value Core DSRIP value
What should providers be
doing to prepare?
Change Management Leadership: Guiding an organization through rapid and
uncharted waters
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So basically we need to :
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• It is not unusual for an organization’s
leadership to believe that it is engaged in
promoting strategic change and for its
workforce to experience shock change.
• Woodward, H. and Woodward, M.B. (1994). Navigating Through Change. NY: McGraw Hill.
Understanding the Impact of
Change on the Workforce
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Leadership and staff members
will need to work together to
support these initiatives in ways
that create synergy within the
organization….
Getting Ready….
• Innovate / Adapt: Consider how your work might need to change in order to support the outcomes required in the transformed system
• Training: Think about the training you will need in order to be successful in this new model –and share your thoughts with your supervisor
• Stay Informed: Read articles and other materials given you to better understand how these changes will impact your work
• Get Involved: Participate in relevant trainings / agency planning sessions
Managed Care Readiness Assessment
Content Areas•Understanding MCO Priorities
•MCO Contracting
•Communication /Reporting
•IT System Requirements
•Credentialing Process
•Level of Care (LOC) Criteria / Utilization Management Practices
•Member Services/Grievance Procedures
•Medical Management
•Quality Management/Quality Studies/Incentive Opportunities
•Finance and Billing
•Access Requirements
•Demonstrating Impact/Value (Data Management & Evaluation Capacity)
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AREAS OF READINESS FOR
MANAGED CARE
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Understanding Managed Care
• Shifting from a volume based to an outcome based
organization
• Clinical and Business Implications
• Transitioning from Utilization Review to Utilization
Management
• Understanding HARP and HCBS
• Role and functions of physicians in a managed care
environment
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Understanding Your Population
• What insurance plans are your clients currently enrolled
in for physical health, or behavioral health as applicable
• Developing an agency wide profile of your population
served and needs including HARP and HCBS
• Understanding your internal service patterns
• Have all your HARP eligible clients been enrolled?
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Contracting
• Understanding current contracts with MCO’s
• Have you met with the MCO’s in your region?
• What is your plan for developing contracts with all
MCO’s in your region?
• How do insurance plans in your region differ across
factors such as authorization, billing, and utilization
management?
• Reporting Requirements for each MCO
• Access Requirements63
Business Operations
• Billing
• Cash Flow Management
• Revenue Cycle Management
• IT
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Utilization Management
• Medical necessity
• Length of stay
• Clinical outcomes
• Level of Care
• Medical Management
• OASAS LOCADTR65
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Data-Driven Decision Making
Making decisions based on available dataProfessional experience – Colleagues – Available data
•What do we already track? What is required and necessary?
•What do we need to track? Requires thinking in advance how data may best inform what we need to know
•How should we track our progress? Implement standard performance-monitoring protocol
•What changes do we need to make? Be willing to adjust measurements intermittently – feedback loop
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Data-Driven Decision Making
Utilizing Data
• All levels of staff will use the best available data
to make informed-decisions
• Clinical staff will collect, monitor, and review clinical
outcome data to make treatment decisions
• Program directors will use outcome data, clinical, claims and
payment data for each service and program to understand
profitability (e.g., cost management, staff management,
reimbursement optimization, and service line profitability)
• Leadership will use data to make decisions about staffing,
and contracting and negotiating leverage
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Data-Driven Decision Making
Thank you very much for your Thank you very much for your
participation!participation!
Contact us: [email protected]
Visit MCTAC’s website for more
information and access to past webinars
and trainings:
http://www.CTACNY.com/ManagedCar
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